Physical therapy management of the subluxated wrist in children with arthritis.

Key Words: Arthritis, Hand, Pediatrics, Physical therapy.

Inflammation of the hand and wrist is common in children with rheumatoid arthritis and may contribute to functional impairment.[1] Although permanent remission may occur, some degree of musculoskeletal damage or loss of hand function may have occurred.[2] Because the wrist joint can fuse as early as 2 years after the onset of the disease,[3] prompt attention and management are required to avoid permanent damage to the joint. The patient with wrist inflammation may have ulnar deviations and decreased wrist extension even before palpable synovitis or other clinical signs of the disease become evident.[4,5] During the acute stages of arthritis, the patient requires close supervision to avoid developing contractures and deformities that presumably occur as a result of pain or effusion.[6,7]

With continued active disease, a number of anatomical and biomechanical factors may cause wrist subluxation. The distal end of the normal radius is inclined in a medial and volar direction.[3] With persistent inflammation, the distal ulna epiphysis may be damaged, the growth plate may close prematurely, and a shortened ulna may result.[3] The normal inclination of the radius and the shortened ulna may cause the carpal bones to slide in an ulnar and volar direction.[5]

Biomechanical factors may predispose the wrist joint to volar subluxation in two ways.[3] When the wrist joint is misaligned, a force generated by the flexor or extensor muscles does not occur perpendicular to the joint, thus increasing the risk of subluxation.[3] The wrist is a multijoint system with both flexor and extensor muscles inserting distally to the joint. Normally, the intrinsic mechanisms, which include the ligaments, provide stabilizing forces to prevent subluxation. In the presence of inflammation, ligaments become lax; combining this with loss of cartilage and joint space, intrinsic support of the wrist is reduced. When the extensor muscles contract without ligamentous support, subluxation may occur at the wrist and midcarpal joints. With contraction of the flexor muscles (especially the flexor carpi ulnaris muscle, which encompasses the pisiform and is anchored to the triquetrum, hamate, and base of the fifth metacarpal by two strong, short ligaments), the carpal bones may move in a volar direction because there is no counteracting force on their extensor aspect.[3] The effects of inflammation on the wrist have been described by Findley et al.[3]

In an inflamed joint, the most comfortable position for the patient is one in which there is ample space to accommodate an effusion, resulting in a low intra-articular pressure with minimal pain.[8] Jason and Dixon[8] reported that in any joint with an effusion resulting in an intra-articular pressure above 30 mm Hg, the flexors reflexively contract and the extensors relax. The most comfortable position for the involved wrist is flexion, which, if maintained too long, may lead to contracture. When attempts are made to stretch the flexion contracture, a force applied distally (ie, along the phalanges) may also result in subluxation of the proximal carpal bones. it is therefore crucial that the force be applied through the proximal carpal row, achieving a stretch but not subluxation.

Wrist subluxation, in our view, may be managed through physical therapy aimed at maximizing realignment of the joint, range of motion (ROM), and strength. At The Hospital for Sick Children (Toronto, Ontario, Canada), we have adapted a protocol for the management of the subluxated wrist in patients with anutis from a model originally developed by the Children's Hospital of Los Angeles (Los Angeles, Calif) (J Mehn, W Hanson, and J Isaacson; unpublished report; 1981). The goals of our protocol were to realign the wrist joint, to increase active range of motion (AROM) and passive range of motion (PROM), and to increase wrist extensor and grip forces.

The purpose of our case report is to describe the application of a physical therapy program for managing a subluxated wrist in patients with arthritis.

Case Report

Physical Therapy Assessment

The inclusion criteria for patients selected for this case report were (1) age less than 18 years and (2) a chagnosis of inflammatory arthritis with a persistent subluxated wrist despite conventional physical therapy consisting of AROM and PROM exercises and day and/or night splinting to maintain correct alignment at the wrist joint. The two patients described in this case report did not respond to conventional physical therapy. Their subluxated wrists continued to progress because of the severity of their joint disease and the lack of consistent support by splinting during this time. At our facility, physical therapy and medical management are usually successful in maintaining ROM and strength in the majority of children with arthritis. When compliance with splinting is poor and the disease activity persists, however, subluxation may occur.

The first patient was a 5.5-year-old girl who was diagnosed with polyarticular juvenile arthritis at the age of 2 years. When first seen in physical therapy, she had a 9-month history of limited movement and pain in her left wrist resulting in decreased active and passive extension and volar subluxation. For 6 months prior to the rehabilitation protocol, she wore a splint during the day on her wrist. At night, her wrist remained unsupported. At the time of the rehabilitation protocol, her disease was being treated with indomethacin (3 cc, by mouth, three times a day), ibuprofen (200 mg, by mouth, four times daily), and D-penicillamine (312 mg, by mouth, four times daily). Her wrist joint was injected in the operating room by the rheumatologist with triamcinolone (1 mg per kilogram of body weight) 24 hours prior to the initiation of physical therapy management.

The second patient was a 17-year-old boy who was diagnosed with psoriatic arthritis at the age of 11 years. His disease was being managed with a regimen of methotrexate, 15 mg once a week, and indomethacin, 50 mg in the morning and at noon and 75 mg slow release at night. When he was first seen in physical therapy, he had a 4-month history of subluxated right wrist. Prior to this physical therapy, patient 2 had been fitted with a night splint for his wrist. He reported not wearing his splint nightly, resulting in inconsistent support of his wrist and leading to subluxation.

Radiographic studies were completed on the wrist of the two patients to determine the degree of joint integrity and the density of the bones. Patient 1 demonstrated a narrowing of the intercarpal joint space associated with articular osteopenia and anterior subluxation at the radiocarpal joint. In patient 2, the radiographs revealed subluxation of the carpal bones anteriorly at the level of the radiocarpal joint.

Photographs were taken prior to the protocol being initiated, with each patient's forearm resting in a pronated position on a flat surface and with the wrist in a neutral position and in extension. The neutral position allowed for detection of the "piano key deformity," which indicates abnormal displacement of the ulna in a dorsal direction.[9] The photograph with the wrist in extension determined whether extension was occurring at the wrist joint or whether the patient was compensating and extending at the carpometacarpal joints.

To establish baseline data, we measured AROM and PROM of wrist flexion and extension with a goniometer, recorded grip force with a modified sphygmomanometer, and tested wrist extensor force isokinetically with the Biodex Isokinetic Dynamometer.(*) This last measure was completed on patient 2 because the device was only available at the time of his assessment. Active range of motion and PROM were measured in accordance with procedures set forth by the American Academy of Orthopaedic Surgeons[10] using the ulnar styloid as the landmark for the center of the goniometer and the medial borders of the ulna and fifth metacarpal as the axis. To maximize reliability of ROM measurements, this standardized method of measurement was applied and the same rater assessed each patient throughout the treatment period. Further, an average of three measurements was used.[11,12]

Grip force was measured with a modified sphygmomanometer using the technique described by the Toronto Arthritis Society Multi-Centre Trial Group.[13] Three trials of grip force were completed on the involved and uninvolved hands, and the best value was chosen.[13] Each grip was sustained for 10 seconds and was measured in millimeters of mercury. Again, the same rater performed the measurements for each patient throughout the treatment. The concurrent validity of the modified sphygmomanometer as compared with free weights has been established by Cole et al.[14] The modified sphygmomanometer, however, measures only static force and not dynamic force, which may limit its concurrent validity with functional activities.[14] Furthermore, the predictive validity of the modified sphygmomanometer has not been established.[14]

For patient 2, wrist force was defined operationally by peak torque concentric values. To determine peak torque, the patient performed five repetitions of wrist flexion and extension at a speed of 180[degrees]/s concentrically. Once the patient was positioned on the Biodex machine, the wrist axis of rotation was aligned to the same vertical and horizontal planes as the power head shaft, and its position was chosen using a line drawn in the sagittal plane through the wrist joint line. Involvement of trunk musculature was minimized by stabilizing the patient with a chest strap. A forearm strap was placed on the midpoint of the forearm. Range of motion limits were set within the patient's available range and verified with a goniometer. Torque resulting from the weight of the hand and shaft lever arm was compensated for by using the software package provided by Biodex. Reliability of this measurement was not assessed.

The Physical Therapy Program

This section will outline the protocol that was generally followed for both patients. During the initial visit, after collecting baseline measurements on AROM and PROM, grip force, and wrist flexor and extensor peak torque, a treatment session was initiated. Tightness in the flexor muscle group occurs as a result of prolonged positioning in flexion to avoid pain and presumably from continued facilitation of the flexor muscles from increased intra-articular pressure.[8] Tightness of the forearm flexor muscle group is defined as an increase in resistance when the wrist joint is passively extended. To decrease this tightness, we had the patients spend 30 minutes in a 9.25X4.75-m hydrotherapy pool with a water temperature of 35[degrees]C. Pool exercises consisted of an entire body warm-up, followed by active wrist extension exercises performed by the patient while standing in shoulder-level water, with the upper arms resting against the trunk, elbows at 90 degrees of flexion, and forearms in neutral to minimize the effects of gravity and to use the effect of buoyancy. The active wrist extension exercises were followed by passive wrist extension exercises performed by the therapist in the same position. Fun activities that incorporated wrist ROM such as ring toss, ball throwing, and volleyball played with a beachban followed.

Following hydrotherapy, five layers of wax were applied by placing the patient's hand and forearm in a Parabath[dagger] and then wrapping the extremity in a towel. The wax remained on for 20 minutes to further relax the muscles and increase tissue extensibility.15 After the wax was removed, we attempted to realign the carpal bones manually by distracting the wrist joint and applying a dorsal force through the volar aspect of the proximal carpal row. When alignment was achieved as determined by a decrease in the piano key sign and an increase in movement at the wrist joint instead of at the carpometacarpal joint, the bones were supported in this position while 10 passive wrist extension stretches (sustaining each stretch for 10 seconds) were performed by the therapist. Care was taken to ensure that the stretching force was at the wrist joint, not distally at the carpometacarpal joint, as this would result in hyperextension of the carpometacarpal joint.

Following the passive extension exercises, a first layer of plaster was applied 2 cm distal to the elbow crease and continued to the metacarpal heads, allowing finger flexion and extension. While the plaster was still pliable, the carpal row was realigned and the wrist was extended to the maximum available ROM and within the pain tolerance of the patient. Once the plaster was dry, maintaining the desired position, two additional layers of plaster were applied to increase the strength and durability of the cast. The cast was left on for 72 hours. Emery and Bowyer[15] have reported that serial casting should be continued every 2 to 3 days until wrist alignment and extension are achieved.

On the second visit, the initial cast was bivalved and carefully removed. To prevent subluxation from reoccurring, the carpal bones were supported by applying a force manually at the volar surface. The wrist and hand were then reassessed. In both patients presented in this report, however, no flexor muscle tightness was apparent when the cast was removed and correct alignment at the wrist joint was achieved. Because maximal wrist extension had not been achieved with the initial cast and to prevent subluxation from recurring due to weak muscles, resting hand splints were fabricated to allow for easier access to the forearm extensors for electrical muscle stimulation (EMS). Emery and Bowyer[15] have reported that it is essential to place the wrist in a splint until the wrist extensors are strong enough to maintain the wrist in extension. A small Polyflexg[R][double dagger] resting hand splint with the wrist maintained in the acquired position was fabricated and applied. To augment the carpal support provided by the splint, Contour Foamo[R][double dagger] was placed inside the splint at the location of the carpal bones, because the wrist extensor muscles were not strong enough to prevent subluxation at the wrist joint. The amount of Contour Foam[R] applied was individually determined to provide full support to the carpal bones and prevent subluxation.

At this stage after the removal of the cast, patient I did not demonstrate a change in wrist extension or grip force. Patient 2 demonstrated a 15-degree increase in AROM and a 20-degree increase in PROM, but a 20-mm Hg decrease in grip force. There was no increase, however, in the percentage of deficit in peak torque that would have identified a decrease in wrist extensor peak torque. Hicks[16] reported that the muscles surrounding a joint with limited movement fatigue faster, as the muscles are at a biomechanical disadvantage. As both patients continued to have limited wrist extension, the goal of physical therapy was to increase PROM while maintaining anatomical alignment at the wrist. Passive range of motion was performed by the therapist, with one of the therapist's hands stabilizing the patient's forearm and the other hand supporting the proximal carpal row while extending the wrist. Two sets of 10 repetitions of PROM of wrist extension were performed, sustaining each stretch for 20 seconds. This stretch was completed at home twice daily by the parent, who had been instructed by the therapist and had demorkstrated an effective technique by practicing first on the therapist and then on the child. Furthermore, the therapist completed a stretch on the child and then had the parent complete the same stretch on the child, allowing the child to compare techniques and provide feedback on technique to the parent.

In addition to the passive wrist extension stretches, a program of strengthening the wrist extensors was initiated, which consisted of EMS using a Respond II[sections] in conjunction with isometric wrist extensor exercises. Hooker[17] stated that muscle reeducation, muscle strengthening, and increasing ROM can be accomplished by electrically stimulating a muscle. Isometric exercises were used with the EMS initially to limit the stress across the joint,6 and until wrist extensor peak torque improved to help maintain correct wrist alignment. The wrist extensor muscle area was cleaned with isopropyl alcohol, and carbon electrodes were then placed on the extensor muscles. The settings used for the EMS were 30 pulses per second with a 10-second on time and a 20-second of time with a rise/fall ratio of 8:3 and a treatment time of 15 minutes. This protocol of PROM and strengthening was initiated immediately after the cast had been removed and the resting hand splint had been applied, and then continued until the patient was able to extend the wrist against gravity while maintaining alignment. All exercises were performed with the wrist positioned in the resting hand splint to provide support and prevent subluxation.

Both patients achieved wrist extension against gravity while maintaining wrist alignment in 2 to 4 weeks, during which the patients were outpatients attending therapy three times per week. This program was continued at home, supervised by a parent who was instructed on the use of EMS and PROM. At each of the visits, the therapist reassessed the patient's wrist and reviewed the home program with the parent to ensure correct technique (ie, proper support of the joint during PROM, application of the appropriate splint, and safe application and use of EMS). Also during each reassessment, the splint was readjusted to assist with maintaining the newly gained range of wrist extension, while Still providing support to the proximal carpal bones to prevent subluxation.

As passive wrist extension and force increased, the patient was instructed with active and active-resisted wrist extension exercises, and these exercises were added to the home program. For active and active-resisted exercises, the forearm was supported by the resting splint with the distal strap unfastened, and the patient actively extended the wrist against gravity to the limit of the available ROM. As force increased, objects with variable weights (eg, soup cans) were used to resist extension. Passive range of motion exercises were continued to further improve wrist extension. Electrical muscle stimulation was also continued but in conjunction with isotonic wrist extension exercises throughout the available ROM as the wrist extensors were now strong enough to maintain alignment of the wrist joint while moving through the ROM. The home program at this time was completed twice daily and consisted of (1) two sets of 10 passive wrist extension stretches with the parent supporting the forearm and the proximal carpal bones as described earlier, (2) two sets of 10 repetitions of active wrist extension and progressing to active-resisted strengthening of the wrist extensor muscles, and (3) EMS with active wrist extension and progressing to active-resisted wrist extension for 15 minutes.

When the patients were not attending physical therapy or completing their home program, they were expected to wear a working or resting splint to prevent subluxation and maintain ROM. A working splint is one that provides full support at the wrist and hand but ends at the heads of the metacarpals, allowing use of the fingers in activities of daily living. During this phase of the protocol, the physical therapy visits were decreased to once a month if the assessment findings indicated that correct alignment of the joint was being maintained and PROM was stable or improving. During each of the visits, the home program was demonstrated by the parent and patient and corrections were made by the therapists, if needed.

As the risk of subluxation was decreased because of improved muscle force at the wrist, wrist extensor peak torque was maintained through an active-resisted exercise program and use of the wrist functionally (eg, dressing, feeding, writing). Electrical muscle stimulation was discontinued once the patient had been assessed using the muscle test grading scale[18] and had achieved grade 5 extensor muscle force within the available ROM into extension. Patient I accomplished grade 5 muscle force within the available ROM 3 months, after the initiation of the protocol, so EMS was discontinued. The patient was expected to continue with the remainder of the home program so that further ROM and wrist extensor peak torque increases could be achieved. With this change in the home program, patient 1 demonstrated a deceleration of 5 degrees of wrist extension in AROM and her PROM plateaued at 65 degrees of wrist extension. As these changes were observed during a reassessment, the home program, which consisted of active-resisted strengthening of the wrist extensors and functional use of the hand (eg, grooming, feeding, writing), was promoted and reviewed. With follow-through of the home program, improvements in grip force and ROM were recorded.

Patient 2 continued with EMS for 5 months as the wrist extensors continued to strengthen, but the ROM had plateaued. Hooker[17] reported that stimulating a muscle group and moving a joint through the ROM help to lengthen the contracted muscle tissue and thus increase ROM. At the end of 5 months, the EMS was discontinued as the patient found that the home program was too lengthy and was interfering with school. At this time, however, patient 2 also demonstrated grade 5 muscle force within the available ROM. The patient was able to maintain his grip force and extensor muscle peak torque with his home program of active-resisted exercises and functional use of the hand.

Time out of the splint during the day was encouraged so that the wrist joint could be challenged without any support and strengthening could occur through functional use. Working and resting splints were discontinued after the patients demonstrated the ability to maintain grade 5 muscle force without the use of the EMS and there were no signs of subluxation or inflammation at the wrist. Patient 1's working splint was discontinued 14 months after the initial casting. The night splint was continued for 3 more months to protect the wrist while sleeping, but was then discontinued as the ROM and grip force had plateaued and had remained stable. The working splint for patient 2 was discontinued 7 months after the casting as the ROM was stable and the wrist extensor peak torque continued to improve. The night splint was continued for 1 more month for protection at night, but was then discontinued with the ROM and grip force stable.

Patient 1 was discharged from physical therapy 14 months after the initial casting for wrist subluxation as her wrist extension AROM had increased 15 degrees, her PROM had increased 30 degrees, and her grip force had been maintained. Follow-up assessments during the physician's clinic at 3 months and 14 months following discharge showed that ROM had been maintained and grip force had increased 50 mm Hg. Patient 2 was discharged from physical therapy 8 months after the initial casting as both his AROM and PROM had increased by 25 degrees, his grip force had increased 60 mm Hg, and his wrist extensor peak torque had decreased by 45%. Follow-up assessment in the physician's clinic 9 months after discharge showed that active wrist extension had been maintained, passive wrist extension increased by 10 degrees, grip force had been maintained, and the percentage of deficit in peak torque decreased. The disease process in both patients remained unchanged during this time period, with no alterations in the medical or pharmacological management.

Discussion

The measurements made in the two patients, as shown in Figures 1 and 2, revealed a long-term improvement in ROM and force. These results seem to demonstrate the potential benefit: of a physical therapy protocol that includes the use of casting in realigning the subluxated wrist joint in children with arthritis. This protocol was well tolerated by the two patients, who to date have not experienced recurrence of wrist subluxation. Although pain and function were not measured in this case study, both patients reported decreased pain and improved function, which allowed them to participate in bilateral hand activities or activities that required weight bearing through the hand with the wrist in extension.

In this protocol, an extensive array of physical therapy modalities with different physiological effects were applied to the patients. Each modality has a specific function but, if used in isolation, may not provide a sufficient treatment.[19] Although there is a clinical rationale for utilizing the combination of physical therapy modalities described in this protocol, further research is necessary to determine whether all of the modalities were required to achieve the desired goal.

One of the components of the protocol was the use of heat. The main objective of this modality was to decrease flexor muscle tightness and increase tissue extensibility. Emery and Bowyer[15] have suggested that heat also appears to affect the gamma fibers in the muscle spindles by decreasing their tendency to contract. Cryotherapy may have physiological effects similar to those of heat; however, an advantage of cryotherapy is the resulting vasoconstriction, which may be beneficial in the presence of edema. Hydrotherapy provides an environment for the patients where not only relaxation occurs, but buoyancy assists with increasing the ROM and muscular strength of the affected joints.[2] Children at our facility appear to prefer the application of heat over ice.

By providing a prolonged stretching force to the joint, casting assists with realigning the subluxated wrist and increasing PROM.[6] In order to maximize the effects of casting, we believe adequate strengthening is mandatory.2 The joint is more prone to deforming forces if it is not adequately stabilized by muscular support.20 Passive range of motion of the joint provides a stretching force to the involved intrinsic components of the wrist,[6] allowing an increase in wrist extension. Passive range of motion alone is not capable of reversing subluxation of joint but must be utilized in conjunction with AROM and strengthening.[6] Active range of motion of the wrist ensures contraction of the extensor muscles, resulting in increased extensor muscle force. Petty[2] Suggests that active exercise is not sufficient to regain diminished ROM. To achieve an increase in extensor muscle force, active-resisted exercises are utilized and the resistance is increased proportionately to the increase in extensor muscle force.[6] Electrical muscle stimulation is used in conjunction with active-resisted exercises to strengthen wrist extensor muscles.

Several factors have the potential to influence the benefits of our protocol. Compliance by the patient with the home program may be an essential component in ensuring a positive outcome. Children under the age of 5 or 6 years appear to tolerate only programs that take 15 to 20 minutes twice daily, and older children appear to tolerate only programs that take 30 minutes twice daily.[2] It is preferable that the patient reside near the hospital to allow for frequent treatment sessions. Otherwise, a period of hospitalization may be required immediately following the removal of the casts to provide the opportunity for strengthening in a concentrated period of time. Financial constraints of the parents must be considered as the EMS machine must be leased and splints must be purchased.

Conclusion

This case report illustrated positive results for the use of casting as an adjunct to physical therapy in managing wrist subluxation in two pediatric patients with arthritis. This case study was limited by a brief baseline phase, the presence of confounding variables (eg, pharmacological therapies), and a lack of functional measures for assessing the effectiveness of physical therapy. Future inquiries based on the results of this case study should include prospective studies (eg, single-subject research design) or group-comparison studies (eg, randomized clinical trials). Research is needed to determine the effectiveness of the protocol with a large sample size, to consider the individual components of the protocol, and to study its effect on daily living and quality of life of the patient.

The results observed in the two patients were encouraging. Casting of other joints (ie, elbow and ankle) has been completed, but the data are still inconclusive. We hope that this report will generate curiosity to investigate this protocol in a research setting as well as provide the clinician with a treatment regimen for management of these difficult joints.

Acknowledgments

We acknowledge the support of the Department of Rehabilitation Services at The Hospital for Sick Children and Dr Ronald Laxer for his contribution to the report.

References

[1] Chaplin D, Pulkki T, Saarimaa A, Vaninio K. Wrist and finger deformities in juvenile rheumatoid arthritis. Acta Rheumatol Scand. 1969; 15:206-233. [2] Petty RE. The treatment of juvenile rheumatoid arthritis. In: McCarty DJ, Koopman WJ, ed. Arthritis and Allied Conditions. 12th ed. Philadelphia, Pa: Lea & Febiger; 1993:1039-1050. [3] Findley TV, Halpern D, Easton JKM. Wrist subluxation in juvenile rheumatoid arthritis: pathophysiology and management. Arch Phys Med Rehabil. 1983;64:69-74. [4] Athreya BH. The hand in juvenile rheumatoid arthritis. In: Proceedings of the first ARA conference on the rheumatoid diseases of childhood. Arthritis Rheum. 1976;20(suppl 2):573-574. [5] Granberry WM, Mangum GL. The hand in the child with juvenile rheumatoid arthritis. J Hand Surg. 1980;5:105-113. [6] Swezey RL. Rehabilitation medicine and arthritis. In: McCarty DJ, Koopman WJ, eds. Arthritis and Allied Conditions. 12th ed. Philadelphia, Pa: Lea & Febiger.: 1993:887-918. [7] Wright DG, Rennels DG. A study of the elastic properties of plantar fascia. J Bone Joint Surg [Am]. 1964;46:482-492. [8] Jason MIV, Dixon ASJ. Intra-articular pressure in rheumatoid arthritis of the knee, III: pressure changes during joint use. Ann Rheum Dis. 1970;29:401-408. [9] McCarty DJ. Differential diagnosis of arthritis: analysis of signs and symptoms. In: McCarly DJ, ed. Arthritis and Allied Conditions. 11th ed. Philadelphia, Pa: Lea Febiger; 1989:65. [10] American Academy of Orthopaedic Surgeons. Joint Motion Method of Measuring and Recording. Edinburgh, Scotland: Churchill Livingstone Ltd; 1983. [11]Low JL. The reliability of joint measurement. Physiotherapy. 1976;62:227. [12] Miller PJ. Assessment of joint motion. In: Rothstein JM, ed. Measurement in Physical Therapy, New York, NY: Churchill Livingstone Inc; 1985:103-136. [13] Helewa A, Goldsmith CH, Smythe HA. The modified sphygmomanometer--an instrument to measure muscle strength: a validation study. J Chronic Dis. 1981;34:353-361. [14] Cole B, Finch E, Gowland C, Mayo N. Modified sphygmomanometer for measuring muscle strength ("Modified Sphyg"). In: Basmajian J, ed. Physical Rehabilitation Outcome Measures. Toronto, Ontario, Canada: Canadian Physiotherapy Association; 1994:40-41. [15] Emery HM, Bowyer SL. Physical modalities of therapy in pediatric rheumatic diseases. Rheum Dis Clin North Am. 1991;17:1001-1014. [16] Hicks JE. Exercise in patients with inflammatory arthritis and connective tissue disease. Rheum Dis Clin North Am. 1990;16:845-870. [17] Hooker D. Electrical stimulating currents. In: Prentice WE, ed. Therapeutic Modalities in Sports Medicine. St Louis, Mo: Times Mirror/ Mosby; 1990:51-81. [18] Magee DJ. Orthopedic Physical Assessment. Philadelphia, Pa: WB Saunders Co; 1987:12. [19] Michlovitz S. The use of heat and cold in the management of rheumatic disease. In: Michlovitz SL, ed. Thermal Agents in Rehabilitation. 2nd ed. Philadelphia, Pa: FA Davis Co; 1990:258-274. [20] Scull SA, Dow MB, Athreya BH. Physical and occupational therapy for children with rheumatic diseases. Pediatr Clin North Am. 1986;33:1053-1077.

(*) Biodex Medical Systems, Brookhaven R&D Plaza, Box 702, Shirley, NY 11967. [dagger] Talcott Laboratories, 301 E Barr St, McDonald, PA 15057. [double dagger] Smith & Nephew Rolyan Inc, 6355 Kesti-al Rd, Mississauga, Ontario, Canada L5T lZ5. [sections] Medtronic Inc, 7000 Central Ave NE, PO Box 1250, Minneapolis, MN 55440.

W Barden, BSc(PT), HBHK, is Physical Therapist, Department of Rehabilitation Services, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. Address all correspondence to Ms Barden.

D Brooks, MSc, BSc(PT), was Clinical Specialist in Research, Education, and Practice, The Hospital for Sick Children, at the time of this study. She is currently Lecturer, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada M5T 1W5.

A Ayling-Campos, BSc(PT), BPHE, is Physical Therapist, Department of Rehabilitation Services, The Hospital for Sick Children.

This article was submitted January 21, 1994, and was accepted June 12, 1995.